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Diagnosis post-BPH op histology v MRI scan

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User
Posted 04 Sep 2024 at 21:07

Hi All -

Just joined this community today Wed 04-Aug-2024.   I have received a diagnosis of low-grade prostate cancer, based on the analysis of tissue removed during a procedure to address BPH.  My primary question is basically: what is the probability of an MRI scan confirming this assessment ?   Or identifying a more problematic status ?    

In 2017 (age 62), following a routine annual company medical exam, and a PSA result (approx 4.1) exceeding 4 for the first time, I was referred to a urologist.  An mpMRI scan showed an enlarged prostate (55cc), but no suspicious lesions.  My urine flow was slow, but the situation was very manageable; in particular I did not have nocturia.  So the diagnosis was BPH.  

I was advised to monitor my PSA level annually, and request a revisit if/when it reached 7.5.    By mid-2023 it had reached 7.2. 

In Aug 2023 (age 68) I had an instance of acute urinary retention requiring emergency catheterisation.  This was followed by a successful TWOC.  In March 2024 I underwent a procedure (Aquablation) to address my BPH.  My pre-surgery prostate size was about 85cc, and although the new size is not yet known, by my estimate is in the range of 31 to 34cc.   This is based on the consultant's indication that typically approx 60% to 63% of the initial tissue volume is removed.  

A flow test and post-void residual test in July 2024 (4 months post-surgery) confirmed that the procedure had, thankfully, successfully addressed the BPH issue, with collateral damage being satisfactorily low.   

However per a post-surgery progress check in Apr 2024 advised that "histology demonstrated a small amount (less than 5% of tissue obtained) of Gleason score six adenocarcinoma cancer of the prostate".  This was followed by various words of a positive and generally reassuring nature.  

I am aware that this outcome is on the bottom rung of the cancer ladder.  And I am comfortable with active surveillance being a good treatment path, assuming that the situation (3+3=6) continues to prevail.  BTW, I did not receive a copy of the histology report/details itself.  

The next planned step is an mpMRI scan (presumably followed by a biopsy if appropriate) and also a PSA test, around the mid Oct.2024.

My understanding is that prostate cancer originates mostly in the peripheral zone, and that BPH surgery focusses on removing tissue from the 'core' (general rather than medical term here) in order to facilitate urine flow.  Therefore it seems to me that the current Gleason 3+3 diagnosis is effectively just a 'baseline' rather than a (reasonably) definitive view of the current status.   Is that a fair view or I am being overly pessimistic ?  Your views and comments are very welcome.   

The secondary reason for asking for your view, is that the medical work between Sep 2023 and today has been done privately, at a pretty significant cost, on a self-funded basis, to which there are limits.....

With the BPH issue having now been addressed, and the focus having moving to the cancer issue, it seems to me to be more sensible to move over to the NHS, bearing in mind my many years of income tax and NICs, and the estimated £1.5k cost of the private MRI.  I am happy with the outcome of the Aquablation procedure, where my consultant is at the forefront of the field and I am sure that he would be excellent in the cancer area too. but at the same time I have necessarily to be mindful of the financial aspect.  

Having had the good fortune to be healthy most of my life so far, I have had very little prior personal contact with either public (ie NHS) or with private medical providers, so it is hard to form a solid view of their overall respective merits, especially for my current situation.  

I do actually have an NHS urology appt lined up in early Oct 2024.  This was set up by my GP, following the Gleason 3+3=6 diagnosis from my consultant in mid-April.  However per my GP, having the histology details is a pre-condition for a meaningful appt with the NHS urologist.  Any views on the likely action (eg MRI scan) and timescale following such a urologist appt ?  

BTW, I live in South West London, which in the coverage area of St Georges Hospital.   

Final general comments: 
- Apologies for the long post.  
- I am aware that, from my brief reading so far in this forum, many members are in very challenging situations, and that my situation is very moderate in comparison, so any comments that you may have would be gratefully and humbly received.   
- I have been very impressed by the high quality of the contributions, and by the high level of mutual support and trust which are so evident here.   

User
Posted 05 Sep 2024 at 00:04

The first thing to say is that it would be more of a surprise if they had not discovered prostate cancer. At age 68 you have a 68% chance of having prostate cancer. Your PSA is about 3 times higher than what would be considered normal for your age, but your prostate is 3 times bigger than normal, so the PSA density is normal, hopefully your next PSA test will be back to the normal range.

This is definitely a cancer that you would not have known about if no one had looked. Now that you know you have it, it should be monitored with active surveillance and an MRI should be part of that. 

I suspect a private urologist is very keen to do their job and find problems, I suspect an NHS urologist may not be so proactive. If I had not been a little more forceful than I should have to be at my first urology appointment my G9 cancer would have slipped through the net. 

I have said on a few posts here, if you're on the NHS you have to manage your own treatment.

Be quite forceful in demanding an MRI. 

Dave

User
Posted 05 Sep 2024 at 08:45

Hi Richard,

Welcome to the forum.

Dave, as usual, has given excellent advice.

In Dec 2020, mid Covid, I was diagnosed with low grade, low volume, T2a, Gleason 6 (3+3), the MRI scan showed the tumour was reasonably contained within the prostate. My PSA at this time was 5.6.

I was advised to go on AS and agreed.

Twenty months later, after having to continually prompt them to do a follow up MRI scan, it had become an extensive disease. 20 out of 24 cores, Gleason 8 (4+4) T3a, capsule breached, PSA only 6.6. I had surgery which upped the Gleason to 9 (4+5)

I don't regret selecting AS but would advise anyone on it, to ensure that the monitoring is active. Although my PSA remained relatively stable, the disease had significantly progressed, showing the need for timely follow up MRIs.

Good luck mate.

 

Edited by member 05 Sep 2024 at 08:47  | Reason: Typo

User
Posted 05 Sep 2024 at 12:28

Hi,

 My primary question is basically: what is the probability of an MRI scan confirming this assessment ?   Or identifying a more problematic status ?    

I had BPH that was resolved with a TURP procedure in 2017. What a relief that was. The histology of the remnant showed Gleason 3+3 in very few cells of the samples taken. To answer your primary question, a follow up MRI showed a lesion graded at Pirads 5 and I was subsequently staged at T2B.

Read my profile for details, but suffice to say that four years later I had RALP when the post op histology showed Gleason 4+3 with 75% of cells being abnormal and stage T3a (extra prostatic extension). My PSA has gradually risen since then and I am now scheduled for salvage radiotherapy.

All of my treatment has been through the NHS and I have no complaints. The timescale from initial consultation with a urologist to speaking with a surgeon and also an oncologist at the same clinic, so that I could decide on treatment, was just 2/3 weeks. At that time, I decided on surgery (my decision to decide quickly, there was no pressure), and was given a date 6 weeks ahead.

I wish you luck with whatever path you take,

Peter

 

 

User
Posted 25 Oct 2024 at 15:21

I am shocked they would go to all the trouble  of doing the MRI fusion directed biopsy and WOULD NOT conduct a systematic core grid collection from all areas of the prostate only pulling cores from the lesion. Once prepared and getting cores it only takes a few extra minutes to collect additional cores. You can read where higher Gleason scores have come from the non targeted areas and the lesions were benign. In my own case my Pirads 4 lesion turned out benign and the other grid cores identified the cancer including one core of a Gleason 8. I would confirm whether this is your Doctor’s true intention and why?

Edited by member 25 Oct 2024 at 15:45  | Reason: Not specified

User
Posted 25 Oct 2024 at 16:09

MRX, 

My MpMRI did identify the lesion which was the only abnormality seen on the MRI and the Radiologist read it as a PIRADS 4. I did have the MRI fusion biopsy and it was specifically targeted at the lesion with the Urologist taking three core samples specifically from the lesion, which later those three samples showed the lesion benign. In addition after targeting the lesion, he began the grid core samples with 12 additional taken, six on each side of the prostate. It was within those samples my cancer was found.

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User
Posted 05 Sep 2024 at 00:04

The first thing to say is that it would be more of a surprise if they had not discovered prostate cancer. At age 68 you have a 68% chance of having prostate cancer. Your PSA is about 3 times higher than what would be considered normal for your age, but your prostate is 3 times bigger than normal, so the PSA density is normal, hopefully your next PSA test will be back to the normal range.

This is definitely a cancer that you would not have known about if no one had looked. Now that you know you have it, it should be monitored with active surveillance and an MRI should be part of that. 

I suspect a private urologist is very keen to do their job and find problems, I suspect an NHS urologist may not be so proactive. If I had not been a little more forceful than I should have to be at my first urology appointment my G9 cancer would have slipped through the net. 

I have said on a few posts here, if you're on the NHS you have to manage your own treatment.

Be quite forceful in demanding an MRI. 

Dave

User
Posted 05 Sep 2024 at 08:45

Hi Richard,

Welcome to the forum.

Dave, as usual, has given excellent advice.

In Dec 2020, mid Covid, I was diagnosed with low grade, low volume, T2a, Gleason 6 (3+3), the MRI scan showed the tumour was reasonably contained within the prostate. My PSA at this time was 5.6.

I was advised to go on AS and agreed.

Twenty months later, after having to continually prompt them to do a follow up MRI scan, it had become an extensive disease. 20 out of 24 cores, Gleason 8 (4+4) T3a, capsule breached, PSA only 6.6. I had surgery which upped the Gleason to 9 (4+5)

I don't regret selecting AS but would advise anyone on it, to ensure that the monitoring is active. Although my PSA remained relatively stable, the disease had significantly progressed, showing the need for timely follow up MRIs.

Good luck mate.

 

Edited by member 05 Sep 2024 at 08:47  | Reason: Typo

User
Posted 05 Sep 2024 at 12:28

Hi,

 My primary question is basically: what is the probability of an MRI scan confirming this assessment ?   Or identifying a more problematic status ?    

I had BPH that was resolved with a TURP procedure in 2017. What a relief that was. The histology of the remnant showed Gleason 3+3 in very few cells of the samples taken. To answer your primary question, a follow up MRI showed a lesion graded at Pirads 5 and I was subsequently staged at T2B.

Read my profile for details, but suffice to say that four years later I had RALP when the post op histology showed Gleason 4+3 with 75% of cells being abnormal and stage T3a (extra prostatic extension). My PSA has gradually risen since then and I am now scheduled for salvage radiotherapy.

All of my treatment has been through the NHS and I have no complaints. The timescale from initial consultation with a urologist to speaking with a surgeon and also an oncologist at the same clinic, so that I could decide on treatment, was just 2/3 weeks. At that time, I decided on surgery (my decision to decide quickly, there was no pressure), and was given a date 6 weeks ahead.

I wish you luck with whatever path you take,

Peter

 

 

User
Posted 25 Oct 2024 at 14:02

First, thanks to all for their previous comments.  And apologies again for another long post, and for some formatting anomalies. 

It seems like there is no answer, at least in the public domain, to my question.  Which is understandable, as I thought that it might provide some reassurance while waiting.  I certainly found that the nearer I got to my MRI, the more tense I became, and the final week was particularly so, impacting my sleep in particular. 

Re the private / NHS options, in the end I made the decision to remain with my private consultant, at least up to the point of the initial MRI.   My overall plan has been to use private services, where necessary and cost-effective to do so, while my issue remained benign or perhaps ‘passive’ i.e. manageable by active surveillance.

I had my MRI on the morning of Mon 14 Oct, saw my consultant at noon on Friday 18th, and received the letter late afternoon Mon 21 Oct.  Summary (italics denote quote from letter; underlines are mine):

Prostate size, PSA 

  • Prostate size now 40ml. Previous size (before procedure to address BPH) size ~85.  Reduction ~53%.

  • PSA now 4. Previously 7.16 in mid-2023, when prostate size was ~80. 

  • PSA density now 0.10ng/ml. Previously 0.09ng/ml.  Slight deterioration, although well within the bounds of measurement error, different laboratories etc.  I was actually rather hoping for a meaningful improvement, on the (possibly misunderstood) basis that BPH was a contributor to elevated PSA.  But that’s now unimportant.

Lesions 

  • “13mm subcapsular lesion between 7 and 8 o’clock within the right mid-gland towards the apex.”

  • “This is characterised as Likert 4 or 5,e. high-risk lesion.”

  • “There is also a smaller 7mm subcapsular lesion in the left mid-gland …

  • …deemed to be indeterminate, i.e. Likert score 3”

  • “We of course picked up the Gleason score 6 adenocarcinoma in the tissue from his aquablation, but we need to understand whether this larger lesion in particular is more significant in terms of its grade or not”.

[this does not seem to actually add anything, given the guidelines, as I understand them, to biopsy any lesion rated Likert / PI-RADS 3 or higher].

Way forward - options

  • (Private) “MR/ultrasound fusion-guided targeted biopsies of the prostate to ensure that we hit this lesion and get accurate information”.

  • In the meeting, consultant said that the biopsy process will target on the identified lesions, and will not include systematic sampling of other areas of the prostate.

  • “….perform this under heavy sedation/a light general anaesthetic.” In the meeting itself, the consultant mentioned sedation, and the associated benefit of the procedure being completely pain-free, in contrast to the procedure using a local anaesthetic. 

  • In the meeting, the consultant mentioned the benefit (accuracy) of fusion guidance, versus cognitive guidance.   

  • The letter does not advise a timeline for the biopsy. In the meeting, the consultant spoke about cancer being a slowing-growing disease but also advised getting the biopsy done before Christmas, which at that time 9 working weeks away, and is now 8.  He indicated that the lead time would be 2 to 3 weeks, with a further 1.5 weeks to cover analysis and presumably the subsequent meeting.  

  • (NHS) The alternative is a 2-week referral from [the GP] to the local department at St George’s where they will perform I suspect cognitive targeted biopsy under local anaesthetic.

Other   

  • In the meeting, the consultant indicated his considered surprise at this MRI outcome, in the context of the earlier post-aquablation (incidental finding) of Gleason 3+3, with volume <5%. Due to limited time, and possibly also due to a degree of shock, I did not pursue this line of discussion.

Comments / Questions for Forum

  • The first thing that I would like to do is, if possible, get a handle of the level of urgency here – is this a ‘pull out all the stops now’ type of situation, or not ?

  • I want to move forward quickly, and ideally would use the NHS, but I am not confident in them delivering a biopsy and result in the pre-Christmas timeframe. My GP has sent me a text to advise a decision need to be made, but the first available appointment is at least a week away.  I may write to him in the meantime.   

  • Given the main lesion size and the Likert rating of at least 4, and possibly 5, I am of course concerned, especially re potential near-term spread to other areas. I have already looked up the Likert (similar to PI-RADS) definitions.

  • I know that DREs have limited diagnostic value. My last one, in approx Aug.2023, was ‘clear’.  Is the position (apex) a contributory reason, or perhaps the lesion was of insufficient size / malignancy 14 months ago ? 

  • I need to do some research on this, so apologies for the naïve question, but I presume that a scan is necessary to detect spread beyond the prostate, and so accurately determine staging. Is there a dependency between the biopsy and the scan, or can the scan be independently ?  

  • Is it possible to make an educated guess on the current stage, based on the limited information so far ?

  • I did a search on ‘subcapsular’ in the forum, which yielded only a handful of results, none of them appearing to be very relevant. Is there any particular significance to its use, or can it be safely disregarded ?

  • Any general comments or suggestions are welcome.

  • For general info, I have previously looked ahead, although in limited detail, at the various treatment options in the event of my situation deteriorating. My general line of thinking was to go for a radical prostatectomy, which I know has a significant downside.  I will be revisiting the options over the next week or so, so things may change. 

  • Also for general info, I was referred to this particular private Urologist for the purpose of the aquablation procedure (which I think has yielded a high quality result), and did not envisage retaining him beyond the completion of that procedure. And there has definitely been a missed opportunity for a previous referral to the NHS track.   Ultimately that was my responsibility, although I now feel that it was based on an inadequate view of the risks.  If I am forced, for time/urgency reasons to remain on the private track I will look for alternatives.   

 

Edited by member 25 Oct 2024 at 14:04  | Reason: Not specified

User
Posted 25 Oct 2024 at 15:21

I am shocked they would go to all the trouble  of doing the MRI fusion directed biopsy and WOULD NOT conduct a systematic core grid collection from all areas of the prostate only pulling cores from the lesion. Once prepared and getting cores it only takes a few extra minutes to collect additional cores. You can read where higher Gleason scores have come from the non targeted areas and the lesions were benign. In my own case my Pirads 4 lesion turned out benign and the other grid cores identified the cancer including one core of a Gleason 8. I would confirm whether this is your Doctor’s true intention and why?

Edited by member 25 Oct 2024 at 15:45  | Reason: Not specified

User
Posted 25 Oct 2024 at 15:47

Thanks Ned@1.  Just read your profile.   So, just to confirm, in your case the mpMRI did not identify, and therefore assist the biopsy process to target, the lesion which turned out to be Gleason 8 ?

I am pretty sure that is what the consultant said.    It did sound slightly strange to me, but being short of time and not being aware of normal practice I did not challenge it, so I do not know the rationale.  The only thing I can think of (and this is pure conjecture) is that he has a very high level of confidence in the MRI's ability to detect potential issues.  It was a 3T machine, in case that makes any difference.     

I will include this point in a list of questions for follow-up with this consultant (or successor).   

 

User
Posted 25 Oct 2024 at 16:09

MRX, 

My MpMRI did identify the lesion which was the only abnormality seen on the MRI and the Radiologist read it as a PIRADS 4. I did have the MRI fusion biopsy and it was specifically targeted at the lesion with the Urologist taking three core samples specifically from the lesion, which later those three samples showed the lesion benign. In addition after targeting the lesion, he began the grid core samples with 12 additional taken, six on each side of the prostate. It was within those samples my cancer was found.

 
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